385
Urological Survey
mal cells membrane and apocrine glandular epithelial cells membrane. There was also ER beta cell membrane
VWDLQLQJLQWKHEDVDODQGVXSUDEDVDOHSLWKHOLDOFHOOVDQG¿EUREODVWVLQWKHODPLQDSURSULD
Conclusions: Established ER presence allows the consideration of the introitus of the vagina as a target for
oes-trogen therapy in various clinical and surgical situations. Continuing elucidation of the immunohistochemistry
of this external genital tissue might assist in the development of molecular tools to treat genital abnormalities.
Details of this immunohistochemistry may also advance the understanding of the effects of sexual
differentia-tion on the brain and other organ systems.
Editorial Comment
7KHVHLQWHUHVWLQJ¿QGLQJVFRQ¿UPRXUEHOLHYHWKDWODELDPLQRUDDQGRWKHUYXOYDUWLVVXHVDUHHVWURJHQ
target structures. It is our practice to administer local estrogen for treating labia minora fusion and other
vul-var diseases in pre-pubertal, pre-menopausal and post-menopausal women. Also, the present data enable us
to expect a greater estrogen effect when administered vaginally, compared with extravaginal administration,
DVWKHDXWKRUVVWDWHG7KHVH¿QGLQJVDUHRIFOLQLFDOLPSRUWDQFHLQWKHSDWKRSK\VLRORJ\RIDJHDVVRFLDWHGDQG
hormonally associated female genital disorders that include both functional and structural changes.
Dr. Francisco J.B. Sampaio
)XOO3URIHVVRUDQG&KDLU8URJHQLWDO5HVHDUFK8QLW
6WDWH8QLYHUVLW\RI5LRGH-DQHLUR
5LRGH-DQHLUR5-%UD]LO
(PDLOVDPSDLR#XURJHQLWDOUHVHDUFKRUJ
RECONSTRUCTIVE UROLOGY _________________________________________________
2SHQVXUJLFDOUHSDLURIXUHWHUDOVWULFWXUHVDQG¿VWXODVIROORZLQJUDGLFDOF\VWHFWRP\DQGXULQDU\
diversion
Msezane L, Reynolds WS, Mhapsekar R, Gerber G, Steinberg G
&KLFDJR3ULW]NHU6FKRRORI0HGLFLQH&KLFDJR,OOLQRLV
J Urol. 2008; 179: 1428-31
Purpose: Open surgery after cystectomy can be a challenge. We report the incidence of postoperative urinary
GLYHUVLRQHQWHULF¿VWXODDQGXUHWHUDOVWULFWXUHVLQSDWLHQWVXQGHUJRLQJUDGLFDOF\VWHFWRP\DQGGLVFXVVWKHGLDJ
-nosis and management of these complications, including our surgical approach to these patients.
Materials and Methods: We preformed a retrospective review of 553 patients undergoing radical cystectomy
and urinary diversion for bladder cancer between April 1999 and January 2007. Patients in whom a ureteral
VWULFWXUHRU¿VWXODGHYHORSHGZHUHLGHQWL¿HGE\VHULDOODERUDWRU\DQGLPDJLQJHYDOXDWLRQV$FKDUWUHYLHZZDV
SUHIRUPHGWRLGHQWLI\V\PSWRPVWLPHWRVWULFWXUHRU¿VWXODGHYHORSPHQWUDGLRORJLFDO¿QGLQJVW\SHRIGLYHU
-sion, estimated blood loss and whether the original anastomosis was stented. Management and outcomes were
assessed.
386
Urological Survey
Conclusions: Open revision remains the gold standard management for ureteral strictures and urinary
diversion-HQWHULF¿VWXODVRFFXUULQJDIWHUUDGLFDOF\VWHFWRP\7KHDGGLWLRQRIWKHFKLPQH\PRGL¿FDWLRQWRWKHRUWKRWRSLF
neobladder facilitates surgical repair.
Editorial Comment
Distal and anastomosis uretral strictures occurring after a cystectomy, following a myriad of diversion
techniques, is not uncommon. Most likely these problems should be performed primarily in the old fashion way,
that is open. In the hands of an experienced endoscopic surgeon the endoureterotomy using a laser can reach a
25% success rate in selected cases as Msezane et al. demonstrated in their retrospective analyzed data.
Sometimes the blood parameters are less sensitive than the follow-up using ultrasound for the upper
urinary tract; therefore, we perform both (1). Similar to the presented data we saw the incidence of strictures
in ureters in different types of diversion. In addition to those who underwent previous radiation, the placing of
an 8F double-J intra-operative might help to reduce the implantation stenoses further (2). Early surgery in our
clinic usually involves the re-implantation of both ureters at the same time which we believe helps to avoid
IXUWKHUFRPSOLFDWLRQV7KHRFFXUUHQFHRI¿VWXODVDVUHSRUWHGLVDUDUHFDVHEXWPLJKWEHKDQGOHGZLWKWLVVXHJOXH
LIWKH¿VWXODLVVPDOOHQRXJKEHIRUHDQRSHQVXUJHU\LVSHUIRUPHG7KHSRVVLELOLWLHVDUHPRUHH[WHQVLYHIRU
the majority of cases, however, in the case of urinary diversions, we should be ready to perform open surgery
IRUERWKFDVHVVWULFWXUHVDQG¿VWXODV
References
1. Nagele U, Kuczyk M, Anastasiadis AG, Sievert KD, Seibold J, Stenzl A: Radical cystectomy and orthotopic bladder replacement in females. Eur Urol. 2006; 50: 249-57.
2. Nagele U, Anastasiadis AG, Merseburger AS, Corvin S, Hennenlotter J, Adam M, et al.: The rationale for radical cystectomy as primary therapy for T4 bladder cancer. World J Urol. 2007; 25: 401-5.
3. Becker HP, Willms A, Schwab R:6PDOOERZHO¿VWXODVDQGWKHRSHQDEGRPHQ6FDQG-6XUJ
Dr. Karl-Dietrich Sievert &
Dr. Arnulf Stenzl
'HSDUWPHQWRI8URORJ\
(EHUKDUG.DUOV8QLYHUVLW\7XHELQJHQ
7XHELQJHQ*HUPDQ\
(PDLODUQXOIVWHQ]O#PHGXQLWXHELQJHQGH
Randomized comparative study between buccal mucosal and acellular bladder matrix grafts in
complex anterior urethral strictures
El Kassaby AW, AbouShwareb T, Atala A
'HSDUWPHQWVRI8URORJ\DQG,QVWLWXWHIRU5HJHQHUDWLYH0HGLFLQH:DNH)RUHVW8QLYHUVLW\+HDOWK6FLHQFHV
:LQVWRQ6DOHP1RUWK&DUROLQDDQG$LQ6KDPV8QLYHUVLW\&DLUR(J\SW
J Urol. 2008; 179: 1432-6
387
Urological Survey
We performed a randomized comparative study to assess the outcome of the acellular bladder matrix compared
to buccal mucosa in patients with complex urethral strictures.
Materials and Methods: Human demineralized bone matrix, obtained from cadaveric donors, was processed
and prepared for use as an off-the-shelf material. Thirty patients with stricture 21 to 59 years old (mean 36.2)
were enrolled and assessed using a standard protocol. The stricture length ranged from 2 to 18 cm (mean 6.9),
of which 11 patients had bulbar, 7 had pendulous and 12 had combined bulbo-pendulous strictures. Of the 30
patients, 7 had received no previous intervention while the remaining 23 had undergone 1 to 7 procedures (mean
1.9). All patients were randomized and alternatively assigned to receive either buccal mucosa or demineralized
bone matrix and underwent an onlay procedure.
Results: All patients except 2 who were lost during followup were followed for 18 to 36 months (mean 25). In
patients with a healthy urethral bed (less than 2 prior operations), the success rate of buccal mucosa grafts (10
of 10) was similar to the bladder matrix grafts (8 of 9) in terms of patency. In patients with an unhealthy urethral
bed (more than 2 prior operations), only 2 of 6 patients with a bladder matrix graft were successful, whereas all 5
SDWLHQWVZLWKDEXFFDOPXFRVDJUDIWKDGDSDWHQWXUHWKUD3RVWRSHUDWLYHXURÀRZPHWU\VKRZHGVLJQL¿FDQWYRLGLQJ
improvement in both groups. Histology of the graft biopsies showed normal urethral tissue characteristics.
Conclusions: This study demonstrates that the use of acellular bladder matrix is a viable option for urethral
repair. Demineralized bone matrix as an off-the-shelf biomaterial achieves the best results in patients with a
KHDOWK\XUHWKUDOEHGQRVSRQJLR¿EURVLVDQGJRRGXUHWKUDOPXFRVD
Editorial Comment
In recent publications, we have seen the reporting of various off-shelf materials for urethral
reconstruc-tion (1,2). Different to the previous publicareconstruc-tions, the authors compared their shelf material “acellular bladder
matrix” against the golden standard of the buccal mucosa graft.
$VZHDOONQRZLQWKHDOPRVWYLUJLQZRXQGEHGWKH¿UVWDSSURDFKDOZD\VVHHPVWRZRUNLISHUIRUPHG
FRUUHFWO\7KHUHIRUHZHVKRXOGDOONHHSLQPLQGWKDWWKH¿UVWDSSURDFKPLJKWEHWKHPRVWLPSRUWDQWLQRUGHU
to have a good outcome in the long term (3). In those cases where more than two previous surgeries were
performed, the best material still seems to be the buccal mucosa. From this well-designed study, we can learn
WKDWDVORQJDVZHGRQRWKDYHWKHSHUIHFWPDWUL[ZHFDQXVHRQHRIIVKHOILQWKH¿UVWUXQWKHUHE\DYRLGLQJWKH
additional surgeries needed to harvest buccal mucosa with a similar outcome within a follow-up of mean two
\HDUV:LWKWKHSDWLHQWZHKDYHWRPDNHWKHGHFLVLRQLIWKH\DUHDOUHDG\UHDG\WRXVHWKLVPDWHULDOLQWKH¿UVW
or second approach (4).
References
1. El-Kassaby AW, Retik AB, Yoo JJ, Atala A: Urethral stricture repair with an off-the-shelf collagen matrix. J Urol. 2003; 169: 170-3; discussion 173.
2. Fiala R, Vidlar A, Vrtal R, Belej K, Student V: Porcine small intestinal submucosa graft for repair of anterior urethral strictures. Eur Urol. 2007; 51: 1702-8; discussion 1708.
3. Sievert KD, Feil G, Renninger M, Selent C, Maurer S, Conrad S, at al.: [Tissue engineering and stem cell research in urology for a reconstructive or regenerative treatment approach] Urologe A. 2007; 46: 1224-30. German. 4. Stenzl A. Urethral reconstruction: new materials but old problems? Eur Urol. 2003; 44: 610.
